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* 1. What is your gender?

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* 2. What is your age?

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* 3. In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

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* 4. Do you have any dietary restrictions? (Select all that apply.)

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* 5. About how many cups of vegetables do you eat each day? If you don’t know for certain, please provide an estimate.

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* 6. Do you have regular transportation to purchase fresh vegetables 

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* 7. Do you know the benefits of eating the correct serving of vegetables a day and how to prepare them?

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* 8. Do you know your last blood pressure and/ or blood glucose reading? please input last reading on others 

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* 9. Have you ever spoken with a dietitian and was it helpful ?

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* 10. Do you feel comfortable preparing meals that include vegetables more often? 

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